“It’s Just Too Much”: The Financial Calculus in Medicare Hospice

Abstract

There is extensive literature on the significance of financial incentives in the Hospice Medicare Benefit (HMB) and the growth of proprietary ownership of hospices in the United States. A literature review indicates a paucity of information on hospice nurses’ and hospice social workers’ perceptions of the impact of the HMB’s financial structure on care planning and delivery decisions. In a previous issue of this journal, the author addressed the literature gap by presenting a study on hospice nurses’ perceptions of the impact of financial factors on their decision-making regarding care for Medicare hospice beneficiaries. The study presented in this article is a companion qualitative study to the nurses’ study. This article presents background on the topic and an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 37 hospice social workers from 6 different hospices between December 1, 2018 and January 31, 2020, in the New York City metropolitan area. Six themes emerged from the interviews: finances are the guiding principle in care planning and service delivery decisions; balancing patient care needs, cost, and finance-related length of stay (LOS) is a challenge; the emphasis on finance diminishes the social workers’ ability to address hospice patient needs; the emphasis on finance diminishes the social workers’ ability to address hospice caregiver needs; the social work role is diminished because of the role of nurses in developing and implementing the plan of treatment, which influences finances; and the Interdisciplinary Team (IDT) is the crucial clinical and financial decision-making setting, but gives limited weight to social work input.